Corticosteroids and COVID-19: What Could Be the Best Bet in Treating Active Glomerular Diseases in Patients With Concomitant Early COVID-19?

To the Editor:

Patients with early mild or asymptomatic coronavirus disease 2019 (COVID-19) who require intense immunosuppression for underlying immune-mediated diseases pose a dilemma to physicians. In severe COVID-19, organ salvaging measures may not seem a top priority. However, because 80% of COVID-19 illnesses are mild, lasting about a week, starting or delaying intense immunosuppression in early mild COVID-19 and active glomerular diseases should be based on informed decision making.

Corticosteroids, often at high doses, remain the cornerstone of treating most glomerular diseases. Use of high-dose (1 mg/kg per day) but not low-dose (<1 mg/kg per day) corticosteroids (methylprednisolone or equivalent) was found to result in prolonged viral shedding (with possible increased hospital stay) and increased risk for mortality in patients with COVID-19. The RECOVERY trial found low-dose corticosteroid treatment (6 mg of dexamethasone) for up to 10 days to be beneficial among hospitalized patients with severe or critical COVID-19. However, the long-term effect of corticosteroids or longer duration of corticosteroid treatment on outcomes of patients with COVID-19 is currently unknown.

We suggest that risk stratification of patients, by balancing the risks of severe COVID-19 with that of irreversible kidney injury, should guide treatment decisions. Currently known risk factors for severe COVID-19 illness (presence of comorbid conditions, lymphopenia, and high viral load) could be incorporated. Although antibody-mediated diseases could possibly be managed with low-dose corticosteroid therapy (~0.5 mg/kg per day of prednisolone) and adjunctive plasmapheresis/intravenous immunoglobulins, other immune-mediated diseases such as podocytopathy and/or acute tubulointerstitial nephritis would typically need high-dose corticosteroids (1 mg/kg per day). In case high-dose corticosteroids are used, covering with an antiviral agent could be done. We believe that more data with antiviral therapy will emerge as trials include patients with kidney disease. Not least of all, shared decision making with the patient must be done after explaining possible benefits and harms of treatment.